Provider Demographics
NPI:1982977278
Name:PARK, GRACE EUNJIN (MD)
Entity Type:Individual
Prefix:DR
First Name:GRACE
Middle Name:EUNJIN
Last Name:PARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5005 N PIEDRAS ST
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79930-5097
Mailing Address - Country:US
Mailing Address - Phone:915-742-1900
Mailing Address - Fax:915-742-9488
Practice Address - Street 1:5005 N PIEDRAS ST
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79930-5097
Practice Address - Country:US
Practice Address - Phone:915-742-1900
Practice Address - Fax:915-742-9488
Is Sole Proprietor?:No
Enumeration Date:2012-02-16
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE27457208D00000X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice